Editorial: A ritual operation

Little is known of the origin of circumcision, despite the very considerable literature on the subject. (1) At its inception the practice seems to have had an essentially religious connotation and to have arisen independently in the continents of Africa, America,* and Australia. Among the Semitic races it is probable that circumcision started as act of consecration to the goddess of fertility with the object of winning her favour and thus ensuring the birth of children. Circumcision in ancient Egypt was certainly not undertaken for hygienic reasons, and probably it served as a sanctification of the reproductive faculties and a ceremonial initiation. It is likely that the ancient Pharaohs were circumcised, the circumcised state being a necessary qualification for the priesthood. It is reported that Pythagoras had himself circumcised while in Egypt so he might be fully initiated into the esoteric religious rites of the Egyptians. Among others, notably the American Indians, circumcision was mainly adopted as an alternative to human sacrifice. Although circumcision is widespread in Moslem communities the Koran contains no specific ordinance on this subject. Mohammed is said to have been born without a prepuce, and the possession of a foreskin was regarded as a disgrace amongst the Arabs. It is reported that after one of the Prophet’s battles a slain Thaquafite tribesman was found uncircumcised, and great pains were taken to prove that he was a Christian and not truly a member of the tribe. In Arab communities the operation is performed with scissors, a razor, or a split reed, and there is a tradition that Abraham used an axe and was rebuked for his haste.

Some of the methods of disposal of the foreskin are more a matter for interest than emulation. The Levites during the Exodus piled their foreskins in the wilderness and covered them with earth; in parts of West Africa, where the operation is performed at about 8 years of age, the prepuce is dipped in brandy and eaten by the patient; in other districts the operator is enjoined to consume the fruits of his handiwork, and yet a further practice, in Madagascar, is to wrap the operation specifically in a banana leaf and feed it to a calf. In happy contrast to some of these macabre practices is the habit of the Bani Chams in Australia with a wooden knife and leave their victims unscathed.

In Britain, while the practice of circumcision is widespread, there are rather different reasons for its performance, and, though exact figures are difficult to obtain, it would seem that more than half the male members of the population are circumcised. Many doctors have for long rebelled against the wholesale and somewhat primitive lopping of the infant foreskin which goes on in some out-patient departments and surgeries. On these occasions the technique of the operation is frequently deplorable ; sacrifice of skin is often too generous, and attendant damage to the glans penis or fraenum is not unknown. If these criticisms are valid then it may well be asked why large numbers of doctors permit and encourage a practice which so savours of the barbaric. Religious considerations apart, it is not easy to find a rational argument for circumcision in most cases, and the operation is more often performed because it is de rigueur in certain districts or a habit in some families.

Dr. Douglas Gairdner’s valuable study, "The Fate of the Foreskin," which appears at page 1433 in this issue, will, we believe, make many readers pause for reflection. Though medical opinion about circumcision may be more conservative than it used to be, yet even to-day the attitude of the profession in general to the subject is too often based upon false ideas of the anatomy and physiology of what is a useful cutaneous appendage. Of the value of the prepuce in the first two or three years of life there is no doubt, for it has an important function in covering and protecting the glans penis. Contrary to widespread belief, non-retractability, a frequent finding, is not synonymous with phimosis. There can be little medical justification for routine circumcision of the infant, and the operation is only occasionally necessary under the age of 3. After this age operation is indicated for cases of non-retractability with true phimosis and for those with recurrent preputial inflammation or paraphimosis. Circumcision should be limited in extent: the fraenal region must not be damaged, and sufficient skin must be left to cover the very sensitive corona glandis. Although the operation of dorsal slit is unpopular with some, it is both satisfactory and simple to perform, and the ultimate cosmetic outcome is good.

Apart from the local reasons for circumcision it is argued by some that it will reduce the incidence of venereal disease, cancer of the penis, and cancer of the cervix uteri. The evidence supporting the first of these contentions is inconclusive ; the second is established beyond doubt ; while the available data on cancer of the cervix do not warrant the conclusions which have been drawn by some authorities. As Dr. Gairdner points out, it is likely that lack of cleanliness is more important than lack of circumcision in the case of venereal diseases and cancer of the penis. If the latter was not a very uncommon disease in this country it alone might provide justification for widespread emulation of the Jewish custom. The Mosaic law enjoins the practice of circumcision on the eighth day, and it appears certain that this ritual circumcision affords complete protection against carcinoma of the penis. Furthermore it has been shown that circumcision between the third and fourteenth years of life does not give complete protection against penile carcinoma.** (2) In the absence of more convincing evidence about carcinoma of the cervix it is difficult to describe its low incidence in Jewesses to the circumcision of their spouses. As Kennaway (3) has pointed out, the data are inadequate, and the low incidence in certain other races cannot be explained by circumcision. It seems safe to say that if Dr. Gairdner’s recommendations are accepted much circumcisional morbidity and mortality will be avoided and, further, that there is no good reason to fear increased incidence of venereal disease or genital cancer as a result of this policy.

* None of the indigenous societies in the Americas (north or south) ever practised circumcision, though there is some evidence that the Aztecs had a ritual which involved nicking the penis to draw blood.

** The statement that "ritual circumcision affords complete protection against carcinoma of the penis" was generally believed in 1949, but this is now known to be false. For more information see pages on circumcision and cancer

EDITORIAL: The case against neonatal circumcision

British Medical Journal, 5 May 1979

Part of the North American way of life is removal of the foreskin within a few hours of birth. Nearly two million boys are born each year in the United States and in some centres 80%-90% are circumcised, [1] using vast amounts of medical and nursing time and costing parents equally vast amounts of money. In Scandinavia, on the other hand. routine circumcision is almost unknown, [2] and in Britain it is becoming unusual. In the 1930s about one-third of British boys were circumcised, [3] but by 1949 the proportion had fallen to one-fifth, [4] and by 1963 only 10% of schoolboys in Rochdale had been circumcised. [5 In hospitals in England and Wales in 1975 the rate was about 6% [6]; this represents some 20,000 circumcisions a year. The mortality is negligible.

Practice in Britain may have been affected by Gairdner’s important paper, [4] published in the BMJ in 1949. He showed that while 90% of boys have an unretractable foreskin at birth by the age of 3 the proportion has dropped to only 10%. Other studies have confirmed this natural development. In over 9000 schoolboys examined in Denmark [7] phimosis was found in 8% of 5-year-olds but in only 1% of secondary pupils. Among 152 teenage English boys only one had a non-retractable foreskin, although full retraction was prevented by an adherent prepuce in 22.

Most circumcisions performed on the newborn are therefore unnecessary – in the sense that in time nearly all boys become able to retract their foreskin and wash underneath it. The North American arguments in favour of mass circumcision are that many uncircumcised men do not perform this toilet, that they run a risk of developing carcinoma of the penis, and that their wives may run an increased risk of developing carcinoma of the cervix. These last two arguments could be weighty ones, but some careful studies [8, 9] have failed to show any difference in the incidence of cervical carcinoma in the wives of circumcised and uncircumcised husbands. Circumcision in infancy does virtually prevent penile carcinoma – there are only six recorded examples of this neoplasm in circumcised Jews. [10] Even in the uncircumcised, however penile carcinoma is rare. In Sweden, which has a male population of 3.7 million (few of whom are circumcised), there are but 15 deaths from carcinoma of the penis in a year. [2] Some 5600 men die each week in England and Wales but only two of these deaths are due to penile carcinoma – only 0.14% of all deaths for malignant disease in men. [11]

Surgeons who work in areas where ritual circumcision is not available are sometimes asked to don rabbinical robes on the eight day to circumcise a Jewish baby, and they may have been impressed by the lack of distress as the baby sucks on a teat containing some brandy. There is however a big difference between these rites and routine circumcision of newborn boys. Too often this is seen as an uninteresting chore to be passed to inadequately trained junior staff, which evidently is not without risk. There are many reports of removal of most of the skin of the penile shaft, injuries to the glans, circumcision of hypospadiacs, and the need to perform a second circumcision on as many as 10% of babies because inadequate removal of mucosa has been followed by secondary phimosis. [1, 12] The present day hospital nursery, often colonised by antibiotic-resistant organisms, is a dangerous place for a newborn baby with a raw penile wound – as is shown by two recent papers. [13,14] These record three babies who developed staphylococcal septicaemia (one fatal) and one with spreading septic gangrene of the scrotal skin after circumcision in the first week of life. Haematogenous osteomyelitis and lung abscess have also been reported as complications. Furthermore, all babies who lose their foreskin lose the natural protection of the glans penis, which prevents it being burnt by ammoniacal urine on the wet nappy. Meatal ulceration is a painful condition and meatal stenosis a serious one.

Presumably most Americans are satisfied with their present practice, and some justify it most forcefully. Others, however do have misgivings, [16] in so far as there is really no rational case for general neonatal circumcision. On the other hand, surgeons and urologists know that many men conceal a dirty mess beneath the foreskin and that in some the discomforts of phimosis make circumcision necessary, and that this is an embarrassing and uncomfortable procedure in adult life. These problems can be forestalled. Examination of the penis, as well as the testes should be a standard part of school medical inspections. This would allow the few boys with true phimosis to be treated early, and at secondary school would provide an excellent opportunity to back up or amplify parental instruction in personal hygiene.

Many surgeons who are not willing to perform circumcision much before three years of age accept that after that age operation is justified for phimosis and recurrent balanitis. The parents’ wishes, both for and against the operation, must be taken into account; but the operation between 3 and 5 is probably the best compromise since it avoids the discomforts of circumcision later in life. Unfortunately only one-third of the operations in England and Wales are before 5 years. [6]. Nevertheless the circumcision rate of about 6% is probably the correct proportion in a Western country today.

NOTE: This editorial expresses the view that about 6% of men need circumcisions. In a later editorial, Saving the normal foreskin, published on 2 January 1993, the BMJ expressed the view that “overall between 1% and 2% of boys need circumcision for medical indications. Since this was before the development of alternative effective conservative treatments for phimosis and balanitis, it may be inferred that the editors of BMJ would put the rate much lower today, perhaps at 0.1% to 0.2% or 1 or 2 per 1000 boys. This would make the arguments expressed in this paper apply with even greater force.

10. Leiter, E, and Lefkovits, A M, New York State Journal of Medicine, 1975, 75, 1520. [Note: Modern research has established the role of the human papilloma virus and smoking in the etiology of carcinoma of the penis and of the cervix. The foreskin has been cleared of blame.]

11. Office of Population Censuses and Surveys, Mortality Statistics: Cause, 1975, Series DH 2 no 2. London HMSO, 1977.